SPORTS INJURIES AND MICRO-TRAUMAS OF ATHLETES. PART II

By Othon Molina, PhD, LMT

In this article, we will discuss the general principles of successful somatic rehabilitation of injured athletes.

TISSUE EVALUATION BY RESISTANCE TESTS

To accurately assess muscles, tendons, ligaments and their attachments to bone, the therapist should examine the presence of pain, tissue weakness or a combination of both. If you’ve worked with patients who are very in tune with their bodies, they will tell you at the beginning: “I feel weak or pain when I do that.” Such information immediately guides your further examination of the area, since if the tissue is strong and painless, there is no problem. However, in many cases, you need to additionally examine the tissue.

If the tissue is weak but not painful, there is a possibility of inadequate innervation of the affected area. In such a case, the motor part of the nerve (which delivers signals from the motor cortex to the muscles) may be mildly irritated without any sign of the sensory part (which delivers signals from peripheral receptors to the brain) being compromised. In these cases, the patient will have weakness without the presence of pain sensation formed in the brain. Another scenario is the presence of a proprioceptive imbalance of innervation in which, as a result of nerve trauma or irritation, normal communication between muscle antagonists is compromised. For example, the patient flexes his elbow using the biceps and feels weakness of flexion, since the triceps, which must be completely relaxed at that moment, did not relax, and as a result, elbow flexion is weakened.
If the examined tissues are painful and weak while being stressed with a resisted movement, a local lesion probably exists. It’s important to apply resistance in exact opposition to the physiological muscle contraction to get an accurate response. After resistance testing is done, palpation to accurately locate the lesion becomes critical.

TENDONS

Tendons are strong bands of collagen fibers united into rope-like structures that attach muscles to bones. They are not as flexible as muscles and are unable to contract, but they are elastic enough to decrease the chance of injury while supporting movement. For example, the contraction of the calf muscle pulls the Achilles tendon up, which in turn pulls the foot down in plantar flexion. If you are bouncing up and down while standing on tiptoe, the elasticity of the tissue that allows you to do that comes partly from the elasticity of the Achilles tendon.

When muscles are shortened by overload, as a result of intense exercise, or as a result of trauma (e.g., muscle strain), the tension of the muscle-tendon complex dramatically increases, especially at the transition of the muscle into the tendon, and eventually it weakens function.

Tendons are more susceptible to injury than muscles for three reasons:

Tendons have a smaller cross section than muscles do. That means they don’t have as large or as wide an area over which force can be distributed. As a result, there is more strain on most tendons than on the muscles during exercise.
Tendons are located in areas where they can be injured easily, especially at their insertion to the bones.
Tendons have very poor blood circulation, and oxygenation of the tendons comes mostly from the process of diffusion, which is a much slower and less efficient way to deliver oxygen to the tissue compared to the direct blood flow which muscles enjoy.

TENDON INFLAMMATION: TENDONITIS

Tendonitis is an inflammation of the tendon or of the sheath that covers the tendon (if it is present), which causes the tendon to swell. Tight muscles or overuse usually causes this. The constant pulling at the tendon irritates it, even when it’s not being exercised.

The situation becomes even worse if the tendon slides over the bone during the muscle contractions. This is seen, for example, in cases of De Quervain’s disease, when the tendons of the abductor pollicis longus and extensor pollicis brevis rub against the periosteum of the styloid process of the radius. The pain is more intense when the patient first rises in the morning. Then it lessens as he or she uses the tendon.

RICE is applied for 24-48 hours after the initial injury. After that time, or in cases of Chronic Tendonitis, the therapist should reduce tension in the fascia, restore the circulation and anatomical length of the muscle the tendon belongs to, and finally use Deep Transverse Friction (DTF) in combination with passive stretching.

I’ve found that DTF doesn’t feel that great, even when there is no injury, so go easy. Read the works of Dr. James Cyriax. I was fortunate to train and study with a doctor who used these methods of DTF. I truly believe in the clinical efficiency of Dr. Cyriax’s work.

TENDON RUPTURE

A tendon rupture is a separation of a tendon from a bone or a muscle, or a complete tear in the tendon itself. Tendon ruptures are usually the result of sudden violent contractions. They occur most often in sports where sudden bursts of speed or changes of direction are required. Athletes who are tight, inflexible and are not properly conditioned, or have not warmed up their muscles, are obviously most susceptible to tendon ruptures.

An athlete can suffer a partial or full tear of the tendon. In both scenarios, surgical restoration of the tendon is the first step to full recovery. Usually, 3 weeks of immobilization of the joint follow and rehabilitation of the tendon can start only after that time. The most frequent areas of tendon rupture are usually the Achilles tendon, the lower tendon of the biceps brachii muscle and, to a lesser degree, the tendon of the quadriceps femoris muscle.

LIGAMENTS

Ligaments are even firmer and less elastic bands than tendons. They attach to the bones where they meet, to form the joint. The main function of ligaments is to stabilize bones when the joint moves. Ligaments are not very flexible, but the worst part is that they have even less blood supply than tendons. In a sense, ligaments are avascular structures, so they heal even slower than tendons. Ligaments don’t like fast, powerful movement, so use care when working with ligaments. Sometimes ligaments can hold the bones together so tightly that there is very little movement of the joint, e.g., the sacroiliac joint.

If some of the ligament fibers are torn, it’s called a sprain. To avoid further tearing of these fibers, the joint should be immobilized immediately. If all of the fibers are torn, the injury is called a complete ligamentous rupture, for which surgery is the only solution.

All joint injuries have the potential to end an athletic career. It doesn’t matter whether they involve bones, cartilage, ligaments, or the muscles and tendons that attach near the joints. All joint injuries are threatening and dangerous for any athlete.

RICE is the first step to a quick recovery. Never exercise or stretch a joint that has just been injured. Like other less elastic tissue, an overstretched ligament results in pain. Ligaments will hurt even with passive movement and ROM. Also, injured ligaments will always hurt with movement of the joint in the direction that the ligament is supposed to stabilize. For example, an injured medial collateral ligament will trigger knee pain on the medial surface of the knee which becomes acute with rotation in the knee. The pain may seem to be more localized than pain from muscle or tendon injuries. Patients usually pinpoint its exact location. DTF on the ligament itself and Periosteal Massage at both insertions of the ligament into the bones are the best treatment options. Also, DTF, while making a ligament stronger, prevents its adhesions.

MUSCLES

Muscles are mostly water – approximately 70%. They are the motors that move every part of the body. You can’t talk, walk, breathe, eat, or drink without using your muscles. They produce movement by contraction or shortening. They pull on the ropes of their tendinous parts and use their attachments to the periosteum of the bones to move the levers (the bones).

MUSCLE SORENESS

There are many kinds of sore muscles. Muscular soreness usually sets in eight to twenty-four hours after heavy or uncommon exercise. General soreness is expected if the muscle was overloaded. At times like these, I have always found that some activity is better than no activity. The following day, I’d feel much better if I swam, went on a short bike ride and did some gentle stretching afterward.

You would be surprised at how many people think it’s good to immediately start to stretch an injured muscle! Don’t start the next day with that. First, do light, repetitive, low-impact exercise before you start stretching. This helps to prevent further injury to the muscle fibers and scarification of the injured site. If, after lifting weights for the first time, you can’t move for three or four days, you have traumatized a number of muscle fibers and definitely overloaded the muscle. The treatment strategy: light repetitive effleurage, gentle circular friction along the belly, kneading in the inhibitory regime and passive stretching.

MUSCLE STRAIN

If the pain is very localized and exceeds 48 hours, the muscle may be injured, usually by a micro-tear. The problem with these injuries is that after they heal, they often trigger scar tissue formation, making the muscle less flexible. When the athlete goes back to training and the muscle didn’t fully recover or wasn’t treated correctly, there is a big chance that the injury will recur.

If the injury is in the belly of the muscle, the athlete should modify the training. In this case, some easy movements and non-weight-bearing exercises can be done. Easy biking or swimming in the first few days could be helpful to prevent scar tissue formation. If the lesion lies toward the tendon, this approach alone is less likely to help, and DTF must be added to the treatment strategy discussed above.

To help runners maintain cardio fitness, I’ve had them work their upper body if the injury is in the lower extremities and they need to stay fit and keep their aerobic conditioning. Because of the law of reversibility, the first area of training to go is aerobic fitness, then endurance, and finally strength.

MUSCLE TEAR

An acute tear of the muscle fibers creates a much more pronounced clinical picture. It is characterized by sudden, localized, persistent and very sharp pain to the point of complete collapse of function. Sometimes the athlete will even hear a popping sound. A muscle tear differs from a muscle strain in the extent of damage.

The muscle can be torn due to:

Mismatch between applied force and muscle’s power
Muscle was not warmed up properly
Decrease of tissue flexibility as a result of chronic microtraumatization
Over-training Syndrome
Imbalance between muscle antagonists. For example, the flexor muscle didn’t completely relax during contraction of the extensor, injuring it.
Structural abnormality. For example, flat feet, even mild scoliosis, etc. may contribute to the damage of the muscle fibers.
Water or mineral deficiency
Lack of an adequate training foundation. The athlete’s tissue endurance must be carefully built up by the coach.

The treatment strategy for a muscle tear is the same: RICE and, later, kneading in the inhibitory regime and careful DTF. However, prolonged rest is critical. Avoid any stretching or deep tissue longitudinal massage strokes directly in the injured area. The athlete should definitely stay away from resistance exercises. The injured muscles will benefit from the passive therapeutic movements during the first few days.

After 10-14 days, if the symptoms persist, Trigger Point Therapy and PNF should be added to enhance the circulation, maintain elasticity and restore anatomical length of the injured muscle.

REVIEW OF THERAPEUTIC TOOLS

DEEP TRANSVERSE FRICTION (DTF) Cyriax’s friction

Should be administered to the exact spot of the problem or to the appropriate tissue.
Should be administered transversely, 90 degrees to the grain of the muscle, tendon, or ligament. The need to know your anatomy becomes clear here.
Friction or spreading the tissue is more important than depth. Use no oil, and apply friction with the skin so that it glides over the underlying tissue. The degree of pressure should be comfortable. Do this at least every other day. Dr. Cyriax believed in a day of rest between treatments.
Hold the tissue in the appropriate tension: the tissue has to have a bit of a stretch to it. It cannot be lax, as that will cause additional irritation.
If DTF is applied to a muscle, it should be at 80% of its maximum tension, so the fibers can be reached and teased apart.
If DTF is applied to a tendon, it should be in the most accessible position, with about 80% stretch. Stay at the tolerance level.
If DTF is applied to a ligament, place the joint at 90% of the ROM controlled by the injured ligament. Massage all the attachments you can reach. The deeper they are, the deeper you have to go. Make sure you work your way down to the deeper levels. You may have to give a few treatments before addressing deeper tissues.
If DTF is applied to a sheathed tendon, the therapist should work with the tendon under 90% stretch. This allows the tendon to form a solid base for the sheath to be rubbed against.

Sheathed tendons can be irritated if the technique is not performed properly.

TRIGGER POINT THERAPY

Trigger Point Therapy is a very important way to release pain and tension in muscles and has become a form of treatment in medicine, physical therapy and massage therapy.

A trigger point is a sensitive point in muscle that, when pressed, triggers a very sharp pain which frequently refers to specific areas. An active trigger point is the epicenter of vasoconstriction, and it prevents full lengthening/shortening of the muscle since lack of proper oxygenation decreases ATP production. ATP is the major energy source for the contraction/relaxation cycle. Thus, when present, trigger point(s) greatly weaken the muscle.

The signs to look for are local tenderness on compression or touch, a taut muscle or nodule, sometimes referred pain shooting along the muscle belly. The acute pain is usually noticed as soon as the therapist presses on the trigger point, and the patient says “Ouch” or what we call the Jump Sign when the patient withdraws the body.

To eliminate the trigger point and the pain it produces, the therapist uses ischemic compression. Remember to stay within the athlete’s tolerance, for up to 60 seconds. Another important issue to consider is the entrance into the trigger point, which is the direction of pressure that elicits the most uncomfortable sensations with the same degree of pressure. The only thing that changes is the angle of pressure application.

To decrease the activity of the pain-analyzing system in the area of the active trigger point, I usually start with the application of massage strokes in the inhibitory regime, then add electric vibration in the fixed regime and only after these preparations start the ischemic compression part of Trigger Point Therapy.

Increase the pressure in steps while giving the athlete a chance to adapt to each level of pressure. Apply pressure in the direction of the entrance into the trigger point detected before ischemic compression started. Make sure that the person you are working on relaxes and breathes regularly. Once you are done with Trigger Point Therapy, you may add PNF contractions and take the muscles through some ROM to further free up the area you are working on. Often I use CTM (Connective Tissue Massage) before Trigger Point Therapy to reduce tension in fascia.

PNF STRETCHES

Proprioceptive Neuromuscular Facilitation stretches (PNF) are an effective way to safely and quickly elongate the affected muscle. PNF is a simple technique; you use muscle contraction to assist a stretch, like a muscle test. In a normal stretch, muscle spindle cells are stretched along with the muscle fibers. These spindle cells send information to the brain, which in turn tells the muscle to stop stretching at a certain point. This is the body’s protective mechanism to keep the muscle from injury.

The PNF stretch must be held 60-90 seconds before the spindle cells begin to shut off. With PNF, the isometric contraction of the muscle and the use of the antagonist muscle increase the effectiveness of the stretch and the relaxation of the targeted muscle.

The isometric contraction of the muscle to be stretched brings blood to the area as well.
The muscle to be stretched is also mildly fatigued by the contraction and wants to relax.
Then the antagonist muscle is contracted, allowing the affected muscle to relax. (This works because as one muscle is contracted, the muscle on the other side of the joint receives a message to release and relax.)